Polycystic ovary syndrome as an independent risk factor for gestational diabetes and hypertensive disorders of pregnancy: a population-based study on 9.1 million pregnancies

Management of hypertensive disorders in pregnancy: a Position Statement of the European Society of Hypertension Working Group 'Hypertension in Women'

Hypertensive disorders in pregnancy (HDP), remain the leading cause of adverse maternal, fetal, and neonatal outcomes. Epidemiological factors, comorbidities, assisted reproduction techniques, placental disorders, and genetic predisposition determine the burden of the disease. The pathophysiological substrate and the clinical presentation of HDP are multifarious. The latter and the lack of well designed clinical trials in the field explain the absence of consensus on disease management among relevant international societies. Thus, the usual clinical management of HDP is largely empirical. The current position statement of the Working Group 'Hypertension in Women' of the European Society of Hypertension (ESH) aims to employ the current evidence for the management of HDP, discuss the recommendations made in the 2023 ESH guidelines for the management of hypertension, and shed light on controversial issues in the field to stimulate future research.

Epidemiology and management of gestational diabetes

Gestational diabetes is defined as hyperglycaemia first detected during pregnancy at glucose concentrations that are less than those of overt diabetes. Around 14% of pregnancies globally are affected by gestational diabetes; its prevalence varies with differences in risk factors and approaches to screening and diagnosis; and it is increasing in parallel with obesity and type 2 diabetes. Gestational diabetes direct costs are US$1·6 billion in the USA alone, largely due to complications including hypertensive disorders, preterm delivery, and neonatal metabolic and respiratory consequences. Between 30% and 70% of gestational diabetes is diagnosed in early pregnancy (ie, early gestational diabetes defined by hyperglycaemia before 20 weeks of gestation). Early gestational diabetes is associated with worse pregnancy outcomes compared with women diagnosed with late gestational diabetes (hyperglycaemia from 24 weeks to 28 weeks of gestation). Randomised controlled trials show benefits of treating gestational diabetes from 24 weeks to 28 weeks of gestation. The WHO 2013 recommendations for diagnosing gestational diabetes (one-step 75 gm 2-h oral glucose tolerance test at 24-28 weeks of gestation) are largely based on the Hyperglycemia and Adverse Pregnancy Outcomes Study, which confirmed the linear association between pregnancy complications and late-pregnancy maternal glycaemia: a phenomenon that has now also been shown in early pregnancy. Recently, the Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) trial showed benefit in diagnosis and treatment of early gestational diabetes for women with risk factors. Given the diabesity epidemic, evidence for gestational diabetes heterogeneity by timing and subtype, and advances in technology, a life course precision medicine approach is urgently needed, using evidence-based prevention, diagnostic, and treatment strategies.

Pregnancy, delivery, and neonatal outcomes among women with PCOS and endometriosis: a population database cohort

PURPOSE

PCOS and endometriosis are independent risk factors for perinatal outcomes. Little research has evaluated the concomitant effects of these conditions, nor have studies been conducted on a population database. We sought to identify the pregnancy, delivery, and neonatal outcomes in women with polycystic ovary syndrome (PCOS) and endometriosis vs. PCOS without endometriosis.

METHODS

A retrospective population-based cohort study was performed extracting data using ICD-9 codes from the HCUP-NIS Database from 2004 to 2014. Endometriosis in women with PCOS represented the study group (n = 163), and the remaining PCOS, non-endometriosis patients constituted the reference group (n = 14,719). Subjects were included once per delivery. Demographics were compared using chi-squared tests. Confounding effects in pregnancy outcomes were controlled using binary logistic regression analysis.

RESULTS

Concomitant endometriosis and PCOS patients were more likely to be white (88.5% vs.71.0%, p < 0.001), with BMI < 30 kg/m2 (87.1% vs.77.8%, p < 0.004) and from lower income quartiles (27.1% vs.17.1%, p < 0.017) when compared to PCOS without endometriosis. Comparing pregnancy complication rates, placental abruption (p < 0.018, aOR 3.01, 95% CI 1.21-7.50), Cesarean section (p < 0.003, aOR 1.75, 95% CI 1.21-2.53), deep venous thromboses (p < 0.002, aOR 74.31, 95% CI 4.57-1209.21), and venous thromboembolic events (p < 0.031, aOR 10.40, 95% CI 1.24-87.37), were increased in the study group compared to the reference group.

CONCLUSION

Women with PCOS and endometriosis were more likely to be white, of lower socioeconomic status, lean, and experience abruptio-placenta, cesarean deliveries, and venous thromboembolisms. Since little was previously known about the combined outcomes of PCOS and endometriosis, it is difficult to counsel patients on risks. Our findings can help clinicians manage pregnant PCOS patients with endometriosis to minimize complications such as abruptio placenta and VTE.

Identification of shared gene signatures and biological mechanisms between preeclampsia and polycystic ovary syndrome

Preeclampsia (PE) is one of the most common complications of pregnancy and polycystic ovary syndrome (PCOS) is a prevalent metabolic and endocrinopathy disorder in women of reproductive age. Identifying the shared genetic signatures and molecular mechanisms between PCOS and PE was the objective of this study. The intersections of WGCNA module genes, PPI module genes, and PPI hub genes revealed that 8 immunity-related genes might be shared causative genes of PE and PCOS. Further, qRT-PCR results showed that TSIX/miR-223-3p/DDX58 might play a crucial role in immune dysregulation in PE and PCOS and Spearman rank correlation analysis results illustrated the potential of DDX58 as a novel diagnostic and therapeutic target for PE and PCOS. Our study demonstrated a common disease pathway model TSIX/miR-223-3p/DDX58, illustrating that immune dysregulation may be a possible mechanism of PE and PCOS, and revealed that DDX58 might be a novel predictive target for PE and PCOS.

The effect of bariatric surgery on polycystic ovary syndrome patients' obstetric and neonatal outcomes: a population-based study

PURPOSE

To examine the effect of bariatric surgery (BS) on obstetric and neonatal outcomes in patients with polycystic ovary syndrome (PCOS).

METHODS

A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database, including women who delivered in the third trimester or had a maternal death in the USA (2004-2014). We compared obstetric and neonatal outcomes between groups in three analyses: (1) Primary analysis-women with an ICD-9 PCOS diagnosis who underwent BS compared to pregnant PCOS patients without BS. (2) Sub-group analysis-PCOS women with BS compared to obese PCOS women (body mass index (BMI) ≥ 30 kg/m2) without BS. (3) Women with and without PCOS who underwent BS.

RESULT

In the primary analysis, pregnant PCOS women who underwent BS (N = 141), compared to pregnant PCOS women without BS (N = 14,741), were less likely to develop pregnancy-induced hypertension (PIH) (9.2% vs. 16.2%, respectively, aOR 0.39, 95% CI 0.21-0.72) and gestational diabetes mellitus (GDM) (9.9% vs. 18.8, aOR 0.40, 95% CI 0.23-0.70). In the sub-group analysis, PCOS women with BS, compared to obese PCOS women without BS (N = 3231), were less likely to develop gestational hypertension, preeclampsia, and preeclampsia or eclampsia superimposed on hypertension (P < 0.05). Lastly, PCOS patients with BS had a higher cesarean section rate when compared to non-PCOS patients with BS (N = 9197) (61.7% vs. 49.2%, aOR 1.48, 95% CI 1.05-2.09), with otherwise comparable obstetric and neonatal outcomes.

CONCLUSIONS

BS in PCOS patients was associated with reduced risks for GDM and PIH when compared to PCOS controls without BS and reduced risk for gestational hypertension, preeclampsia, and preeclampsia or eclampsia superimposed on hypertension when compared to obese PCOS controls without BS. Moreover, BS was associated with reduced inherent pregnancy risks of PCOS, almost equating them to those of non-PCOS counterparts.

Polycystic ovary syndrome

Despite affecting ~11-13% of women globally, polycystic ovary syndrome (PCOS) is a substantially understudied condition. PCOS, possibly extending to men's health, imposes a considerable health and economic burden worldwide. Diagnosis in adults follows the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome, requiring two out of three criteria - clinical or biochemical hyperandrogenism, ovulatory dysfunction, and/or specific ovarian morphological characteristics or elevated anti-Müllerian hormone. However, diagnosing adolescents omits ovarian morphology and anti-Müllerian hormone considerations. PCOS, marked by insulin resistance and hyperandrogenism, strongly contributes to early-onset type 2 diabetes, with increased odds for cardiovascular diseases. Reproduction-related implications include irregular menstrual cycles, anovulatory infertility, heightened risks of pregnancy complications and endometrial cancer. Beyond physiological manifestations, PCOS is associated with anxiety, depression, eating disorders, psychosexual dysfunction and negative body image, collectively contributing to diminished health-related quality of life in patients. Despite its high prevalence persisting into menopause, diagnosing PCOS often involves extended timelines and multiple health-care visits. Treatment remains ad hoc owing to limited understanding of underlying mechanisms, highlighting the need for research delineating the aetiology and pathophysiology of the syndrome. Identifying factors contributing to PCOS will pave the way for personalized medicine approaches. Additionally, exploring novel biomarkers, refining diagnostic criteria and advancing treatment modalities will be crucial in enhancing the precision and efficacy of interventions that will positively impact the lives of patients.

The effect of socioeconomic status on adverse obstetric and perinatal outcomes in women with polycystic ovary syndrome-An evaluation of a population database

OBJECTIVE

To evaluate the modifying effect of low socioeconomic status (SES) on polycystic ovary syndrome (PCOS) women's pregnancy and neonatal complications.

METHODS

A retrospective population-based cohort study including all women with an ICD-9 diagnosis of PCOS in the US between 2004 and 2014, who delivered in the third trimester or had a maternal death. SES was defined according to the total annual family income quartile for the entire population studied. We compared women in the lowest income quartile (<$39 000 annually) to those in the higher income quartiles combined (≥$39 000 annually). Pregnancy, delivery, and neonatal outcomes were compared between the two groups.

RESULTS

Overall, 9 096 788 women delivered between 2004 and 2014, of which 12 322 had a PCOS diagnosis and evidence of SES classification. Of these, 2117 (17.2%) were in the lowest SES group, and 10 205 (82.8%) were in the higher SES group. PCOS patients in the lowest SES group, compared to the higher SES group, were more likely to be younger, obese (body mass index ≥30 kg/m2 ), to have smoked tobacco during pregnancy, and to have chronic hypertension and pregestational diabetes mellitus (DM) (P < 0.05). In a multivariate logistic regression, women in the lowest SES group, compared to the higher SES group, had increased odds of pregnancy-induced hypertension (aOR 1.27, 95% CI: 1.12-1.46, P < 0.001), pre-eclampsia (aOR 1.37, 95% CI: 1.14-1.65, P < 0.001), and cesarean delivery (aOR 1.21, 95% CI: 1.09-1.34, P < 0.001), with other comparable pregnancy, delivery and neonatal outcomes.

CONCLUSION

In PCOS patients, low SES increases the risk for pregnancy-induced hypertension, pre-eclampsia and CD, highlighting the importance of diligent pregnancy follow-up and pre-eclampsia prevention in these patients.

Idiopathic intracranial hypertension and obstetric and neonatal outcomes: A 1:20 matched study from a population database

OBJECTIVE

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a common pathology in reproductive-aged women, although data regarding pregnancy outcomes are scarce. In the present study, we aimed to compare pregnancy and perinatal outcomes between women who suffered from IIH to those who did not.

METHODS

A retrospective cohort study using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample. All pregnant women who delivered or had a maternal death in the US (2004-2014) were included. Women with an ICD-9 diagnosis of IIH before or during pregnancy were matched to controls without IIH according to age, race, insurance type, and income quartile, in a 1:20 ratio. Pregnancy, delivery, and neonatal outcomes were compared between the two groups.

RESULTS

Overall, 9 096 788 deliveries were identified. Of these, 1454 women (0.016%) had a diagnosis of IIH (study group) and were compared to 29 080 women without IIH (control group). Women with IIH, compared to those without, were more likely to be obese (body mass index >30 kg/m2) and suffer from pregestational diabetes mellitus and chronic hypertension (P < 0.001, all). After adjusting for confounders, patients in the IIH group, compared to those without, had a higher rate of pregnancy-induced hypertension (aOR 1.82, 95% CI: 1.57-2.1, P < 0.001), pre-eclampsia (aOR 1.98, 95% CI: 1.61-2.45, P < 0.001), preterm delivery (aOR 1.88, 95% CI: 1.59-2.23, P < 0.001), CD (aOR 2.41, 95% CI: 2.12-2.73, P < 0.001), wound complications (aOR 3.2, 95% CI: 1.89-5.42, P < 0.001), and congenital anomalies (aOR 2.18, 95% CI: 1.4-3.4, P < 0.001).

CONCLUSION

Women with IIH had a higher incidence of obstetrical complications, including preterm deliveries, hypertensive disorders of pregnancy, and congenital anomalies.

Investigating the causal impact of polycystic ovary syndrome on gestational diabetes mellitus: a two-sample Mendelian randomization study

Introduction

Determining the causal relationship between polycystic ovary syndrome (PCOS) and gestational diabetes mellitus (GDM) holds significant implications for GDM prevention and treatment. Despite numerous observational studies suggesting an association between PCOS and GDM, it remains unclear whether a definitive causal relationship exists between these two conditions and which specific features of PCOS contribute to increased incidence of GDM.

Methods

The causal relationship between polycystic ovary syndrome (PCOS), its characteristic indices, and gestational diabetes mellitus (GDM) was investigated using a two-sample Mendelian randomization study based on publicly available statistics from genome-wide association studies (GWAS). The inverse-variance weighted method was employed as the primary analytical approach to examine the association between PCOS, its characteristic indices, and GDM. MR Egger intercept was used to assess pleiotropy, while Q values and their corresponding P values were utilized to evaluate heterogeneity. It is important to note that this study adopts a two-sample MR design where PCOS and its characteristic indices are considered as exposures, while GDM is treated as an outcome.

Results

The study results indicate that there is no causal relationship between PCOS and GDM (all methods P > 0.05, 95% CI of OR values passed 1). The IVW OR value was 1.007 with a 95% CI of 0.906 to 1.119 and a P value of 0.904. Moreover, the MR Egger Q value was 8.141 with a P value of 0.701, while the IVW Q value was also 8.141 with a P value of 0.774, indicating no significant heterogeneity. Additionally, the MR Egger intercept was 0.0004, which was close to zero with a P value of 0.988, suggesting no pleiotropy. However, the study did find a causal relationship between several other factors such as testosterone, high-density lipoprotein, sex hormone-binding globulin, body mass index, waist-hip ratio, apolipoprotein A-I, number of children, diabetes illnesses of mother, father and siblings, hemoglobin A1c, fasting insulin, fasting blood glucose, years of schooling, and GDM based on the IVW method.

Conclusion

We observed no association between genetically predicted PCOS and the risk of GDM, implying that PCOS itself does not confer an increased susceptibility to GDM. The presence of other PCOS-related factors such as testosterone, high-density lipoprotein, and sex hormone-binding globulin may elucidate the link between PCOS and GDM. Based on these findings, efforts aimed at preventing GDM in individuals with PCOS should prioritize those exhibiting high-risk features rather than encompassing all women with PCOS.

Metabolic hormones are integral regulators of female reproductive health and function

The female reproductive system is strongly influenced by nutrition and energy balance. It is well known that food restriction or energy depletion can induce suppression of reproductive processes, while overnutrition is associated with reproductive dysfunction. However, the intricate mechanisms through which nutritional inputs and metabolic health are integrated into the coordination of reproduction are still being defined. In this review, we describe evidence for essential contributions by hormones that are responsive to food intake or fuel stores. Key metabolic hormones-including insulin, the incretins (glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1), growth hormone, ghrelin, leptin, and adiponectin-signal throughout the hypothalamic-pituitary-gonadal axis to support or suppress reproduction. We synthesize current knowledge on how these multifaceted hormones interact with the brain, pituitary, and ovaries to regulate functioning of the female reproductive system, incorporating in vitro and in vivo data from animal models and humans. Metabolic hormones are involved in orchestrating reproductive processes in healthy states, but some also play a significant role in the pathophysiology or treatment strategies of female reproductive disorders. Further understanding of the complex interrelationships between metabolic health and female reproductive function has important implications for improving women's health overall.

Bisphenol a downregulates GLUT4 expression by activating aryl hydrocarbon receptor to exacerbate polycystic ovary syndrome

BACKGROUND

Bisphenol A (BPA) levels are high in women with polycystic ovary syndrome (PCOS). The mechanism by which BPA induces abnormal glucose metabolism in PCOS patients is largely unknown.

METHODS

Serum and urine samples were collected from women with and without PCOS (control) at the reproductive medicine center with informed consent. Non-PCOS patients who received in vitro fertilization were recruited for collection of ovarian follicular fluid and granular cells. Wild-type C57BL/6 and AhR -/- mice were used to verify the effects of BPA on PCOS. Real-time PCR, western blotting, and ELISA were conducted to analyze the function of BPA. Chip-qPCR verified the role of AhR in GLUT4 transcription. Flow cytometry was performed to determine glucose uptake.

RESULTS

A positive correlation was observed between BPA concentration and serum BPA levels in PCOS patients. BPA aggravated the changes in PCOS with abnormal glucose metabolism, impaired fertility, and increased body fat. Mechanistically, we showed that BPA activated AhR and led to decreased glucose transport via GLUT4 downregulation in ovarian granular cells. Therefore, the use of inhibitors or knockout of AhR could effectively rescue BPA-induced metabolic disorders in PCOS mice.

CONCLUSIONS

Our results revealed that BPA suppressed GLUT4 expression and induced abnormal glucose metabolism by activating AhR, causing insulin resistance, and is thus a potential contributor to the development of PCOS. Therefore, AhR could be a potential new therapeutic target for PCOS. Video Abstract.

Birth outcomes in mothers with hypertensive disorders and polycystic ovary syndrome: a population-based cohort study

STUDY QUESTION

Is polycystic ovary syndrome (PCOS) associated with higher risks of extreme birth size and/or preterm birth in mothers with different hypertension types?

SUMMARY ANSWER

PCOS was associated with additional risks of preterm birth in mothers with chronic hypertension and in singleton pregnancies of mothers with pre-eclampsia, and with higher risks of offspring born large for gestational age (LGA) in mothers with gestational hypertension.

WHAT IS KNOWN ALREADY

Women with PCOS are more likely to develop gestational hypertension, pre-eclampsia, and chronic hypertension. Although adverse birth outcomes have been frequently reported in mothers with PCOS, such associations in the setting of a hypertensive disorder remain unknown.

STUDY DESIGN SIZE DURATION

This is a population-based cohort study including all live births 2004-2014 in Finland (n = 652 732). To ensure diagnosis specificity, mothers with diagnoses that could cause signs and symptoms resembling PCOS were excluded.

PARTICIPANTS/MATERIALS SETTING METHODS

Maternal diagnoses of PCOS, gestational hypertension, chronic hypertension, and pre-eclampsia were identified from the Finnish national registries. Generalized estimating equation and multivariable logistic regression were used to assess the adjusted odds ratio (aOR) and 95% CIs of preterm birth, very preterm birth, and offspring being small for gestational age (SGA) or LGA in hypertensive mothers with or without PCOS, using normotensive mothers without PCOS as reference.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 43 902 (6.7%) mothers with hypertensive disorders, 1709 (3.9%) had PCOS. Significant interactions were detected for PCOS with hypertension on preterm birth, very preterm birth, offspring born SGA and LGA (Fpreterm = 504.1, Pinteraction < 0.001; Fvery preterm = 124.2, Pinteraction < 0.001; FSGA = 99.5, Pinteraction < 0.001; FLGA = 2.7, Pinteraction = 0.012, respectively). Using mothers with no hypertensive disorder and no PCOS as reference, the risks of preterm and very preterm birth were overrepresented in non-PCOS mothers with chronic hypertension or pre-eclampsia. PCOS was associated with higher risks of preterm birth (aORPCOS 4.02, 3.14-5.15 vs aORnon-PCOS 2.51, 2.32-2.71) in mothers with chronic hypertension, with significant interaction between the exposures (F = 32.7, Pinteraction < 0.001). PCOS was also associated with a higher risk of preterm birth in singleton pregnancies of mothers with pre-eclampsia (aORPCOS 7.33, 5.92-9.06 vs aORnon-PCOS 5.72, 5.43-6.03; F = 50.0, Pinteraction < 0.001). Furthermore, the associations of PCOS comorbid with chronic hypertension or pre-eclampsia was detected also for spontaneous births. Moreover, the risk of offspring LGA was higher in mothers with PCOS and gestational hypertension although lower in those with gestational hypertension alone (aORPCOS 2.04, 1.48-2.80 vs aORnon-PCOS 0.80, 0.72-0.89; F = 9.7, Pinteraction = 0.002), whereas for offspring SGA, the risks were comparable between hypertensive mothers with and those without PCOS.

LIMITATIONS REASONS FOR CAUTION

Information on medication treatment, gestational weeks of onset for pre-eclampsia and gestational hypertension, weight gain during pregnancy, and PCOS phenotypes were not available. All diagnoses were retrieved from registries, representing only those seeking medical care for their symptoms. The ICD-9 codes used to identify PCOS before year 1996 are known to underestimate the prevalence of PCOS, while the inclusion of anovulatory infertility as PCOS might introduce an overrepresentation bias, although PCOS constitutes 80% of anovulatory infertility. The risk of very preterm birth in relation to maternal PCOS and hypertensive disorders should be interpreted with caution owing to limited sample sizes. Multifetal pregnancies among maternal PCOS were too few for a subgroup analysis. Moreover, ART included IVF/ICSI only. Potential effects of other treatments, such as ovulation induction, were not examined.

WIDER IMPLICATIONS OF THE FINDINGS

PCOS was associated with additional risks of preterm birth or offspring being LGA in hypertensive mothers, which varied between hypertension types. The exacerbated risks highlight consideration of PCOS in pregnancy counseling and management for women with hypertensive disorders.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by Shandong Provincial Natural Science Foundation, China [ZR2020MH064 to X.C.], the joint research funding of Shandong University and Karolinska Institute [SDU-KI-2019-08 to X.C. and C.L.], the Finnish Institute for Health and Welfare: Drug and pregnancy project [M.G.], the Swedish Research Council [2022-01188 to C.L.], the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institute Stockholm County Council [RS2021-0855 to C.L.], the Swedish Brain Foundation [FO2021-0412 to C.L.]. The funders had no role in study design, data collection, analysis, and interpretation, writing of the report or decision to submit for publication. The authors report no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Examination of newborn DNA methylation among women with polycystic ovary syndrome/hirsutism

Research suggests that polycystic ovary syndrome (PCOS) traits (e.g., hyperandrogenism) may create a suboptimal intrauterine environment and induce epigenetic modifications. Therefore, we assessed the associations of PCOS traits with neonatal DNA methylation (DNAm) using two independent cohorts. DNAm was measured in both cohorts using the Infinium MethylationEPIC array. Multivariable robust linear regression was used to determine associations of maternal PCOS exposure or preconception testosterone with methylation β-values at each CpG probe and corrected for multiple testing by false-discovery rate (FDR). In the birth cohort, 12% (102/849) had a PCOS diagnosis (8.1% PCOS without hirsutism; 3.9% PCOS with hirsutism). Infants exposed to maternal PCOS with hirsutism compared to no PCOS had differential DNAm at cg02372539 [β(SE): -0.080 (0.010); FDR p = 0.009], cg08471713 [β(SE):0.077 (0.014); FDR p = 0.016] and cg17897916 [β(SE):0.050 (0.009); FDR p = 0.009] with adjustment for maternal characteristics including pre-pregnancy BMI. PCOS with hirsutism was also associated with 8 differentially methylated regions (DMRs). PCOS without hirsutism was not associated with individual CpGs. In an independent preconception cohort, total testosterone concentrations were associated with 3 DMRs but not with individual CpGs, though the top quartile of testosterone compared to the lowest was marginally associated with increased DNAm at cg21472377 near an uncharacterized locus (FDR p = 0.09). Examination of these probes and DMRs indicate they may be under foetal genetic control. Overall, we found several associations among newborns exposed to PCOS, specifically when hirsutism was reported, and among newborns of women with relatively higher testosterone around conception.

Gestational Diabetes Mellitus in the Setting of Polycystic Ovarian Syndrome: A Systematic Review

Gestational diabetes mellitus (GDM) is the most common complication of pregnancy that arises in the 2nd and 3rd trimesters, leading to significant complications for the mother and her neonates, such as an increased rate of pregnancy-induced hypertension and miscarriages, while neonates may have a large birth weight, hypoglycemia, or macrosomnia. Numerous risk factors can lead to GDM; however, a significant one is polycystic ovarian syndrome (PCOS). PCOS is the most common endocrine pathology beginning before puberty, and due to significant hormonal changes, it is not diagnosed until after puberty. PCOS requires at least three of the following symptoms: hyperandrogenism, menstrual irregularities, or polycystic ovary morphology. While it is agreed that women with PCOS are at a significantly increased risk of GDM, no publication to our knowledge has evaluated the full relationship of GDM in the setting of PCOS. This paper aimed to assess this relationship and determine how it may differ for pregnant women with only GDM by determining the prevalence of GDM, the variations within phenotypes, the influence of fertilization methods, specific risk factors, maternal outcomes, and neonatal outcomes. The prevalence of GDM was significantly increased in women with PCOS compared to healthy controls, and some studies have found that phenotype A may be more likely to lead to GDM. Risk factors were similar to pregnant women with only GDM, but with GDM and PCOS specifically, preconception low sex hormone-binding globulin, increased BMI > 25 kg/m2, and preconception impaired glucose tolerance were specific. While maternal outcomes were similar to pregnant women with only GDM, women with GDM and PCOS were even more likely to develop pregnancy-induced hypertension and early miscarriage. Neonates from mothers with GDM and PCOS were more likely to have low birth weights compared to mothers with just GDM who had high birth weights. The evaluation of the relationship between GDM and PCOS allows for illumination of the need to evaluate influences that currently lack research, such as phenotype variation and influences of fertilization method. This also promotes the need to develop predictive algorithms based on risk factors to prevent these adverse outcomes for mothers and neonates.

Progress of the application clinical prediction model in polycystic ovary syndrome

Clinical prediction models play an important role in the field of medicine. These can help predict the probability of an individual suffering from disease, complications, and treatment outcomes by applying specific methodologies. Polycystic ovary syndrome (PCOS) is a common disease with a high incidence rate, huge heterogeneity, short- and long-term complications, and complex treatments. In this systematic review study, we reviewed the progress of clinical prediction models in PCOS patients, including diagnosis and prediction models for PCOS complications and treatment outcomes. We aimed to provide ideas for medical researchers and clues for the management of PCOS. In the future, models with poor accuracy can be greatly improved by adding well-known parameters and validations, which will further expand our understanding of PCOS in terms of precision medicine. By developing a series of predictive models, we can make the definition of PCOS more accurate, which can improve the diagnosis of PCOS and reduce the likelihood of false positives and false negatives. It will also help discover complications earlier and treatment outcomes being known earlier, which can result in better outcomes for women with PCOS.

Integrative Analysis of Core Genes and Biological Process Involved in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common gynecological endocrine disordered disease, affecting the function of the ovaries in women of reproductive age. However, there are limited curative therapies for PCOS due to lack of reliable candidates. Hence, this study aimed to identify hub pathogenic genes and potential therapeutic targets for PCOS using bioinformatics tools. We obtained the expression profiles of 29 PCOS samples and 24 normal samples from three Gene Expression Omnibus (GEO) datasets. Then, the differentially expressed genes (DEGs) were screened, which were subjected to functional enrichment analyses. Moreover, we found 30 ferroptosis-related genes out of the 89 DEGs. Among the top 10 significant ferroptosis-related DEGs, 8 genes showed good predictive performance. We constructed interaction network of top three ferroptosis-related DEGs (SLC38A1, ACO1, DDIT3). Finally, real-time PCR was performed to test the relative expression of these genes. In conclusions, we have identified ferroptosis-related DEGs as core genes and potential therapeutic targets of PCOS based on comprehensive bioinformatics analysis. The findings are conducive to understanding of the pathogenesis of PCOS and paving the way towards curative therapies.

Increased Risk of Preeclampsia with Assisted Reproductive Technologies

PURPOSE OF REVIEW

We summarized recent available data to assess the association between assisted reproductive technology (ART) and risk for preeclampsia.

RECENT FINDINGS

The majority of clinical studies supporting the association of preeclampsia and ART are retrospective. Published data from both clinical and pre-clinical studies suggest specific ART procedures may contribute to the increased risk, including in vitro embryo handling and development, hormone stimulation, transfer cycle types, and use of donor oocytes/embryos. Potential mechanisms include epigenetic aberrations leading to abnormal placentation, absence of factors secreted by the corpus luteum, and immunologic responses to allogenic gametes. There is an increased risk of preeclampsia following ART. Treatment plans that favor reduced preeclampsia risk should be considered for ART pregnancies. To make ART pregnancies safer, additional clinical and animal model studies are needed to elucidate the underpinnings of this risk association.

Immunomodulatory Effects of Metformin Treatment in Pregnant Women With PCOS

CONTEXT

Polycystic ovary syndrome (PCOS) is a common endocrine disorder associated with low-grade systemic inflammation and increased risk of pregnancy complications. Metformin treatment reduces the risk of late miscarriage and preterm birth in pregnant women with PCOS. Whether the protective effect of metformin involves immunological changes has not been determined.

OBJECTIVE

To investigate the effect of metformin on the maternal immunological status in women with PCOS.

METHODS

A post-hoc analysis was performed of two randomized controlled trials, PregMet and PregMet2, including longitudinal maternal serum samples from 615 women with PCOS. Women were randomized to metformin or placebo from first trimester to delivery. Twenty-two cytokines and C-reactive protein were measured in serum sampled at gestational weeks 5 to 12, 19, 32, and 36.

RESULTS

Metformin treatment was associated with higher serum levels of several multifunctional cytokines throughout pregnancy, with the strongest effect on eotaxin (P < .001), interleukin-17 (P = .03), and basic fibroblast growth factor (P = .04). Assessment of the combined cytokine development confirmed the impact of metformin on half of the 22 cytokines. The immunomodulating effect of metformin was more potent in normal weight and overweight women than in obese women. Moreover, normoandrogenic women had the strongest effect of metformin in early pregnancy, whereas hyperandrogenic women presented increasing effect throughout pregnancy.

CONCLUSION

It appears that metformin has immunomodulating rather than anti-inflammatory properties in pregnancy. Its effect on the serum levels of many multifunctional cytokines demonstrates robust, persisting, and body mass-dependent immune mobilization in pregnant women with PCOS.

Diabetes detection in women with gestational diabetes and polycystic ovarian syndrome

Gestational diabetes mellitus (GDM) and polycystic ovarian syndrome (PCOS) represent two of the highest risk factors for development of type 2 diabetes mellitus in young women. As these increasingly common conditions generally affect younger women, early detection of dysglycemia is key if preventative measures are to be effective. While international guidance recommends screening for type 2 diabetes, current screening strategies suffer from significant challenges.First, guidance lacks consensus in defining which tests to use and frequency of monitoring, thereby sending mixed messages to healthcare professionals.Second, conformity to guidance is poor, with only a minority of women having tests at the recommended frequency (where specified). Approaches to improve conformity have focused on healthcare related factors (largely technology driven reminder systems), but patient factors such as convenience and clear messaging around risk have been neglected.Third, and most critically, current screening strategies are too generic and rely on tests that become abnormal far too late in the trajectory towards dysglycemia to offer opportunities for effective preventative measures. Risk factors show wide interindividual variation, and insulin sensitivity and β cell function are often abnormal during pre-diabetes stage, well before frank diabetes.New, consistent, targeted screening strategies are required that incorporate early, prevention focused testing and personalised risk stratification.

[Polycystic ovary syndrome as a gender-specific cardiometabolic risk factor]

With a prevalence of 15%, polycystic ovary syndrome (PCOS) is the most common endocrinopathy in fertile-aged women. Insulin resistance and obesity play a pivotal role in the pathophysiology of PCOS, modulate the severity of symptoms and are associated with an increased risk for cardiometabolic sequelae such as diabetes, non-alcoholic fatty liver disease and atherosclerotic cardiovascular disease. PCOS should be considered as a gender-specific cardiovascular risk factor. Therefore, if traits indicative for PCOS are present, affected women should undergo PCOS diagnostics as a first step, thereby making it possible to initiate cardiovascular primary prevention strategies in this population of young women at high cardiometabolic risk. In women with known PCOS, screening and treatment of cardiometabolic risk factors and/or diseases should be routinely integrated into the concept of PCOS care. The close link between insulin resistance/obesity and PCOS can be used to improve PCOS-specific symptoms and enhance cardiometabolic health.

Risk prediction of gestational diabetes mellitus in women with polycystic ovary syndrome based on a nomogram model

Women with polycystic ovary syndrome are prone to develop gestational diabetes mellitus, a disease which may have significant impact on the postpartum health of both mother and infant. We performed a retrospective cohort study to develop and test a model that could predict gestational diabetes mellitus in the first trimester in women with polycystic ovary syndrome. Our study included 434 pregnant women who were referred to the obstetrics department between December 2017 and March 2020 with a diagnosis of polycystic ovary syndrome. Of these women, 104 were diagnosed with gestational diabetes mellitus in the second trimester. Univariate analysis revealed that in the first trimester, Hemoglobin A1c (HbA1C), age, total cholesterol(TC), low-density lipoprotein cholesterol (LDL-C), SBP (systolic blood pressure), family history, body mass index (BMI), and testosterone were predictive factors of gestational diabetes mellitus (P < 0.05). Logistic regression revealed that TC, age, HbA1C, BMI and family history were independent risk factors for gestational diabetes mellitus. The area under the ROC curve of the gestational diabetes mellitus risk prediction model was 0.937 in this retrospective analysis, demonstrating a great discriminatory ability. The sensitivity and specificity of the prediction model were 0.833 and 0.923, respectively. The Hosmer-Lemeshow test also showed that the model was well calibrated.

The association between hypothyroidism and perinatal outcomes in patients with polycystic ovary syndrome

PURPOSE

To compare pregnancy, delivery, and neonatal outcomes in patients with polycystic ovary syndrome (PCOS) with and without concomitant hypothyroidism.

METHODS

A retrospective population-based cohort study including all women with an ICD-9 diagnosis of PCOS in the US between 2004 and 2014, who delivered in the third trimester or had a maternal death. We compared women with a concomitant diagnosis of hypothyroidism to those without. Women with hyperthyroidism were excluded. Pregnancy, delivery, and neonatal outcomes were compared between the two groups.

RESULTS

Overall, 14,882 women met inclusion criteria. Among them, 1882 (12.65%) had a concomitant diagnosis of hypothyroidism, and 13,000 (87.35%) did not. Women with concomitant hypothyroidism, compared to those without, were characterized by increased maternal age (25.5% ≥ 35 years vs. 18%, p < 0.001, respectively), and had a higher rate of multiple gestations (7.1% vs. 5.7%, p = 0.023). Interestingly, pregnancy, delivery and neonatal outcomes were comparable between the groups, except for a higher rate of small-for-gestational-age (SGA) neonates in the group with hypothyroidism (4.1% vs. 3.2%, p = 0.033) (Tables 2 and 3). In a multivariate logistic regression adjusting for potential confounders, hypothyroidism was no longer found to be associated with SGA (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 0.99-1.75, p = 0.057), but was found to increase the odds for preeclampsia (aOR 1.30, 95% CI 1.06-1.59, p = 0.012).

CONCLUSIONS

In patients with PCOS, concomitant hypothyroidism significantly increases the risk for preeclampsia. Unexpectedly, other pregnancy complications commonly increased by hypothyroidism were not increased in women with PCOS, likely due to the inherent elevated baseline pregnancy risks of PCOS.

Fetal sex and the development of gestational diabetes mellitus in polycystic ovarian syndrome gravidae

BACKGROUND

Polycystic ovarian syndrome is characterized by elevated androgens and is a well-known risk factor for the occurrence of gestational diabetes mellitus. Androgens (particularly dehydroepiandrosterone-sulfate) are crucial for the development and characteristics of the male reproductive tract during fetal life, and fetal dehydroepiandrosterone-sulfate enters the placenta where it is metabolized and functions as an estrogen substrate. Given this unique sex-specific relationship with androgens and the association of serum dehydroepiandrosterone-sulfate concentration with insulin resistance, we hypothesized that metabolic comorbidities in pregnancy might differ by fetal sex in gravidae with polycystic ovarian syndrome, notably in those with infertility.

OBJECTIVE

This study aimed to evaluate the data in a large population-based database to explore if fetal sex was significantly associated with gestational diabetes mellitus in gravidae with infertility and polycystic ovarian syndrome after controlling for confounders.

STUDY DESIGN

This study was designed to evaluate the risk for the occurrence and rates of gestational diabetes mellitus among gravidae with infertility and a history of polycystic ovarian syndrome. We used a 2-hospital, single academic institution database comprising more than 30,000 subjects enrolled from September 2011 to June 2021 to identify all gravidae with diagnoses of infertility and polycystic ovarian syndrome at the time of delivery and to compare them with gravidae who lacked these comorbidities. Data on covariates, including but not limited to maternal age, body mass index, fetal sex, race, ethnicity, presence or absence of hypertensive disease, and presence or absence of gestational diabetes were identified. Unadjusted and adjusted odds rations were calculated.

RESULTS

We found a statistically significant association between fetal female sex and the development of gestational diabetes mellitus in gravidae with polycystic ovarian syndrome (odds ratio for female vs male, 2.13; 95% confidence interval, 1.06-4.32; P=.03). After adjusting for potential confounders identified in our univariate analyses, there continued to be a statistically significant association between female fetuses and the development of gestational diabetes mellitus (adjusted odds ratio for female vs male, 2.10; 95% confidence interval, 1.04-4.41; P=.04). In contrast, there was no significant association between fetal sex and the development of gestational diabetes mellitus in our similar analysis of gravidae without infertility and polycystic ovarian syndrome (P=.99).

CONCLUSION

Although the origin of gestational diabetes mellitus is multifactorial, we found that female fetal sex is associated with gestational diabetes mellitus in gravidae with infertility and polycystic ovarian syndrome but not in their comparative controls. Further research on the molecular mechanisms driving the association between female fetuses and the development of gestational diabetes mellitus in the context of maternal polycystic ovarian syndrome is warranted.

Impact of Adverse Gestational Milieu on Maternal Cardiovascular Health

Cardiovascular disease affects 1% to 4% of the nearly 4 million pregnancies in the United States each year and is the primary cause of pregnancy-related mortality. Adverse pregnancy outcomes are associated with cardiovascular complications during pregnancy persisting into the postpartum period. Recently, investigations have identified an altered sex hormone milieu, such as in the case of hyperandrogenism, as a causative factor in the development of gestational cardiovascular dysfunction. The mechanisms involved in the development of cardiovascular disease in postpartum women are largely unknown. Animal studies have attempted to recapitulate adverse pregnancy outcomes to investigate causal relationships and molecular underpinnings of adverse gestational cardiac events and progression to the development of cardiovascular disease postpartum. This review will focus on summarizing clinical and animal studies detailing the impact of adverse pregnancy outcomes, including preeclampsia, gestational diabetes mellitus, and maternal obesity, on gestational cardiometabolic dysfunction and postpartum cardiovascular disease. Specifically, we will highlight the adverse impact of gestational hyperandrogenism and its potential to serve as a biomarker for maternal gestational and postpartum cardiovascular dysfunctions.

Androgen-Induced Cardiovascular Risk in Polycystic Ovary Syndrome: The Role of T Lymphocytes

An estimated 15-20% of reproductive-age women are affected by polycystic ovary syndrome (PCOS). PCOS is associated with substantial metabolic and cardiovascular long-term consequences. In young women with PCOS, several cardiovascular risk factors may be found, including chronic inflammation, high blood pressure, and elevated leukocytes. These women are at an increased risk of cardiovascular diseases (CVD), not only during the reproductive years, but also with aging and menopause; therefore, the early prevention and treatment of future cardiovascular adverse effects are necessary. The fundamental characteristic of PCOS is hyperandrogenemia, which is associated with increased pro-inflammatory cytokines and T lymphocytes. Whether these factors play a role in the pathophysiology of hypertension, a risk factor of CVD, due to PCOS is not well established. This review will briefly discuss how a modest increase in androgens in females is linked to the development of hypertension through pro-inflammatory cytokines and T lymphocyte subsets and the promotion of renal injury. Moreover, it reveals a few existing research gaps in this area, including the lack of specific therapy directed at androgen-induced inflammation and immune activation, thus emphasizing the necessity to explore the systemic inflammation in women with PCOS to halt the inevitable inflammatory process targeting the underlying abnormalities of CVD.

Risk of Gestational Diabetes and Pregnancy-Induced Hypertension with a History of Polycystic Ovary Syndrome: A Nationwide Population-Based Cohort Study

OBJECTIVE

To evaluate the risks of developing gestational diabetes (GDM) and pregnancy-induced hypertension (PIH) in women with polycystic ovary syndrome (PCOS) using data from Korea's National Health Insurance Service.

METHOD

The PCOS group comprised women aged 20 to 49 years diagnosed with PCOS between 1 January 2012, and 31 December 2020. The control group comprised women aged 20 to 49 years who visited medical institutions for health checkups during the same period. Women with any cancer within 180 days of the inclusion day were excluded from both the PCOS and control groups, as were women without a delivery record within 180 days after the inclusion day, as well as women who visited a medical institution more than once before the inclusion day due to hypertension, diabetes mellitus (DM), hyperlipidemia, DM in pregnancy, or PIH. GDM and PIH were defined as cases with at least three visits to a medical institution with a GDM diagnostic code and a PIH diagnostic code, respectively.

RESULTS

Overall, 27,687 and 45,594 women with and without a history of PCOS experienced childbirth during the study period. GDM and PIH cases were significantly higher in the PCOS group than in the control group. When adjusted for age, SES, region, CCI, parity, multiple pregnancies, adnexal surgery, uterine leiomyoma, endometriosis, PIH, and GDM, an increased risk of GDM (OR = 1.719, 95% CI = 1.616-1.828) was observed among women with a history of PCOS. There was no increase in the risk of PIH among women with a history of PCOS (OR = 1.243, 95% CI = 0.940-1.644).

CONCLUSION

A history of PCOS itself might increase the risk of GDM, but its relationship with PIH remains unclear. These findings would be helpful in the prenatal counseling and management of patients with PCOS-related pregnancy outcomes.

Adverse obstetric outcomes in women with PCOS and multiple gestations

RESEARCH QUESTION

Does multiple gestation alter the risks for adverse obstetric outcomes in women with polycystic ovary syndrome (PCOS)?

DESIGN

Retrospective population-based cohort study using data from the HCUP-NIS from 2004 to 2014. A total of 14,882 women with PCOS, who delivered within that time period, were identified. The study group comprised women with PCOS who had had a multiple gestation (n = 880); the reference group was comprised of the remaining women with PCOS and singleton gestation (n = 14,002).

RESULTS

In women with PCOS, multiple gestation increased the risks of pregnancy complications including pregnancy-induced hypertension (adjusted odds ratio [aOR] 2.030; 95% confidence interval [CI] 1.676-2.460), pre-eclampsia (aOR 2.879; 95% CI 2.277-3.639), pre-eclampsia and eclampsia superimposed on pre-existing hypertension (aOR 1.917; 95% CI 1.266-2.903) and gestational diabetes (aOR 1.358; 95% CI 1.114-1.656). Multiple gestation increases the risk of preterm premature rupture of membranes (aOR 5.807; 95% CI 4.153-8.119), preterm delivery (aOR 8.466; 95% CI 7.071-10.135), Caesarean section (aOR 5.146; 95% CI 4.184-6.329), post-partum haemorrhage (aOR 1.540; 95% CI 1.065-2.228) and the need for transfusion (aOR 3.268; 95% CI 2.010-5.314), as well as wound complications (aOR 3.089; 95% CI 1.647-5.794). Neonates born to mothers with PCOS and having multiple gestations are more likely to be small for gestational age when compared to singleton neonates born to mothers with PCOS (aOR 4.606; 95% CI 3.480-6.095). Among PCOS women with multiple gestations, obesity increased the risks of developing pregnancy-induced hypertension (P < 0.001), pre-eclampsia (P < 0.001) and wound complications (P = 0.045).

CONCLUSION

These results highlight the importance of single embryo transfer and ovulation induction to develop a single follicle in women with PCOS. Obesity further increases obstetrical complications.

Idiopathic Hirsutism and Metabolic Status: A Population-based Prospective Cohort Study

BACKGROUND

A limited number of studies have investigated the impact of idiopathic hirsutism (IH) on cardiometabolic parameters with contradictory and inconclusive results. This study aimed to explore the effect of IH on metabolic outcomes.

METHOD

In this population-based prospective study, 334 women with IH and 1226 women as healthy controls were selected from Tehran Lipid and Glucose Study. The generalized estimation equations method was applied to investigate the secular longitudinal trends of metabolic indices, including fasting blood sugar (FBS), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL), non-HDL, triglyceride (TG), systolic blood pressure (SBP), diastolic blood pressure (DBP), and waist circumference (WC) in both groups. Unadjusted and adjusted Cox regression models were applied to assess the hazard ratios (HR) and 95% CIs for the association between IH and metabolic disorders. Potential confounding factors such as age, body mass index, smoking, physical activity, history of hypertension (HTN), and family history of diabetes were included in the adjusted model.

RESULTS

This study showed that compared with healthy controls, women with IH had lower SHBG and higher total testosterone (median [interquartile ratio; IQR]: 0.37 [0.16-0.70] vs 0.33 [0.14-0.58]; P = 0.01), free androgen index (median [IQR]: 0.85 [0.38-1.54] vs 0.54 [0.26-0.97]; P = 0.001), androstenedione (median [IQR]: 1.60 [1.00-2.25] vs 1.10 [0.90-1.70]; P = 0.001), and dehydroepiandrosterone sulfate (median [IQR]: 168.5 [91.1-227.8] vs 125.2 [66.3-181]; P = 0.001). Over time, mean changes of FBS, HDL-C, LDL-C, non-HDL-C, TG, SBP, DBP, and WC were not significantly different in women with IH, compared with healthy controls. According to the unadjusted Cox regression model, except for type 2 diabetes mellitus (T2DM) (HR [95% CI]: 1.45 [1.00-2.11]) P = 0.05; there was no statistically significant difference in hazard of metabolic disorders (ie, HTN, pre-HTN, pre-T2DM, and metabolic syndrome) in IH, compared with healthy controls. Besides, the adjusted Cox regression model showed no significant differences in the hazard of these outcomes.

CONCLUSION

This study showed no significant difference in overtime mean changes of metabolic risk factors and cardiometabolic outcomes in women with IH, compared with the healthy control group, except marginally significant difference on T2DM, which disappeared after further adjustment for potential confounders. Accordingly, routine screening of women for these metabolic outcomes should not recommend.

A Prospective Study to Determine the Predictive Ability of HDP-Gestosis Score for the Development of Pre-eclampsia

Background

HDP-gestosis score is a risk scoring system (score 1-3) for the development of pre-eclampsia. When a pregnant woman's total score is equal to or greater than 3, she is labelled as "at risk for pre-eclampsia" and is managed accordingly.

Objectives

To determine the sensitivity, specificity, Positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of HDP-gestosis score for predicting pre-eclampsia.

Methods

This prospective study included 473 pregnant women who presented at the department of Obstetrics and Gynaecology, from June 2020 to December 2021. After 20 weeks of pregnancy, the patients were assessed for the development of pre-eclampsia. Details of age, gravida, obstetric history, menstrual cycle regularity, polycystic ovarian disease history, duration of marriage, parity, past medical and surgical intervention, previous/present medication, and family history were taken. Gestosis score was calculated and classified into mild (score of 1), moderate (score of 2) and high risk (score of ≥ 3) for the development of Pre-eclampsia (PE). Sensitivity, Specificity, PPV, NPV and diagnostic accuracy of HDP-gestosis score for predicting the development of PE were determined.

Results

The mean age, gestational age, and BMI of the women were 28.4 ± 6.8 years, 11.5 ± 2.04 weeks, and 24.5 ± 3.7 kg/m^2, respectively. The gestosis score was 2 in 43.13% of the participants, 1 in 42.28%, and ≥ 3 in 14.59% of the women. PE developed in 15.01% (n = 71) participants. The Sensitivity, Specificity, PPV, NPV, and Diagnostic accuracy of HDP-gestosis score for predicting PE were 83.1%, 97.51%, 85.51%, 97.03% and 95.35%, respectively.

Conclusion

Gestosis score is a novel early marker for prediction of the development of PE allowing for a prompt management for the patients, thereby curbing the adverse consequences.

Polycystic Ovarian Syndrome (PCOS): Does the Challenge End at Conception?

Polycystic ovary syndrome (PCOS) is a prevalent condition that not only has the potential to impede conception but also represents the most common endocrine dysfunction in fertile women. It is considered a heterogeneous and multifaceted disorder, with multiple reproductive and metabolic phenotypes which differently affect the early- and long-term syndrome's risks. Undoubtedly, the impact of PCOS on infertility has attracted most of the attention of healthcare providers and investigators. However, there is growing evidence that even after conception is achieved, PCOS predisposes the parturient to several adverse pregnancy outcomes including a high risk of pregnancy-induced hypertension, spontaneous abortion, gestational diabetes, preeclampsia, and preterm birth, which increase the risks of stillbirth and neonatal death. Fetal growth abnormalities may also be more common, but the relationship is less well defined. This narrative review aims to summarize current knowledge regarding these conditions as they interplay with PCOS and concludes that although there appears to be an increase in these complications during the pregnancy of women with PCOS, there is a need for further research to clarify the possible confounding impact of obesity. Implications for clinical practice and future research are outlined.

PCOS and the risk of pre-eclampsia

RESEARCH QUESTION

What is the association between polycystic ovary syndrome (PCOS) and pre-eclampsia? Data suggest that patients with PCOS are at increased risk of developing pre-eclampsia; however, several studies have not found an independent association between the two.

DESIGN

A retrospective case-control study of singleton deliveries at a tertiary care hospital from 2011 to 2015. Patients with pre-eclampsia (cases) were matched to the next delivery without pre-eclampsia (controls) on gestational age week. Medical history data, a diagnosis or clinical features of PCOS and obstetric data, including pre-eclampsia, were abstracted from the medical record. Groups were compared with the chi-squared test, and conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (95% CI). OR were adjusted for maternal age at delivery and race/ethnicity.

RESULTS

This study included 435 cases and 435 controls. Cases were more likely to be Black compared with controls. Age, comorbidities, features of PCOS and use of IVF were similar between groups. Patients with pre-eclampsia were not more likely to have PCOS (8.3%) than those without pre-eclampsia (6.2%, adjusted OR 1.40, 95% CI 0.81-2.30). Sensitivity analyses for body mass index and parity suggested an increased pre-eclampsia risk for patients with PCOS and these additional factors, however no group showed a statistically significant association between PCOS and pre-eclampsia.

CONCLUSIONS

In this study, a history of PCOS was not associated with the risk of pre-eclampsia. Further investigation is necessary to determine whether there are subgroups of PCOS patients who are at increased risk of pre-eclampsia.

Polycystic ovary syndrome and risk of adverse pregnancy outcomes: a registry linkage study from Massachusetts

STUDY QUESTION

Do women with polycystic ovary syndrome (PCOS) have a greater risk of adverse pregnancy complications (gestational diabetes, preeclampsia, cesarean section, placental abnormalities) and neonatal outcomes (preterm birth, small for gestational age, prolonged delivery hospitalization) compared to women without a PCOS diagnosis and does this risk vary by BMI, subfertility and fertility treatment utilization?

SUMMARY ANSWER

Deliveries to women with a history of PCOS were at greater risk of complications associated with cardiometabolic function, including gestational diabetes and preeclampsia, as well as preterm birth and prolonged length of delivery hospitalization.

WHAT IS KNOWN ALREADY

Prior research has suggested that women with PCOS may be at increased risk of adverse pregnancy outcomes. However, findings have been inconsistent possibly due to lack of consistent adjustment for confounding factors, small samples size and other sources of bias.

STUDY DESIGN, SIZE, DURATION

Massachusetts deliveries among women ≥18 years old during 2013-2017 from state vital records linked to hospital discharges, observational stays and emergency department visits were linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) and the Massachusetts All-Payers Claims Database (APCD).

PARTICIPANTS/MATERIALS, SETTING, METHODS

PCOS was identified by ICD9 and ICD10 codes in APCD prior to index delivery. Relative risks (RRs) and 95% CI for pregnancy and delivery complications were modeled using generalized estimating equations with a log link and a Poisson distribution to take multiple cycles into account and were adjusted a priori for maternal age, BMI, race/ethnicity, education, plurality, birth year, chronic hypertension and chronic diabetes. Tests for homogeneity investigated differences between maternal pre-pregnancy BMI categories (<30, ≥30, <25 and ≥25 kg/m2) and between non-infertile deliveries and deliveries that used ART or had a history of subfertility (defined by birth certificates, SART CORS records, APCD or hospital records).

MAIN RESULTS AND THE ROLE OF CHANCE

Among 91 825 deliveries, 3.9% had a history of PCOS. Women with a history of PCOS had a 51% greater risk of gestational diabetes (CI: 1.38-1.65) and a 25% greater risk of preeclampsia (CI: 1.15-1.35) compared to women without a diagnosis of PCOS. Neonates born to women with a history of PCOS were more likely to be born preterm (RR: 1.17, CI: 1.06-1.29) and more likely to have a prolonged delivery hospitalization after additionally adjusting for gestational age (RR: 1.23, CI: 1.09-1.40) compared to those of women without a diagnosis of PCOS. The risk for gestational diabetes for women with PCOS was greater among women with a pre-pregnancy BMI <30 kg/m2.

LIMITATIONS, REASONS FOR CAUTION

PCOS was defined by ICD documentation prior to delivery so there may be women with undiagnosed PCOS or PCOS diagnosed after delivery included in the unexposed group. The study population is limited to deliveries within Massachusetts among most private insurance payers and inpatient or observational hospitalization in Massachusetts during the follow-up window, therefore there may be diagnoses and or deliveries outside of the state or outside of our sample that were not captured.

WIDER IMPLICATIONS OF THE FINDINGS

In this population-based study, women with a history of PCOS were at greater risk of pregnancy complications associated with cardiometabolic function and preterm birth. Obstetricians should be aware of patients' PCOS status and closely monitor for potential pregnancy complications to improve maternal and infant perinatal health outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the NIH (R01HD067270). S.A.M. receives grant funding from NIH, AbbVie and the Marriot Family Foundation; payment/honoraria from the University of British Columbia, World Endometriosis Research Foundation and Huilun Shanghai; travel support for attending meetings for ESHRE 2019, IASP 2019, National Endometriosis Network UK meeting 2019; SRI 2022, ESHRE 2022; participates on the data safety monitoring board/advisory board for AbbVie, Roche, Frontiers in Reproductive Health; and has a leadership role in the Society for Women's Health Research, World Endometriosis Research Foundation, World Endometriosis Society, American Society for Reproductive Medicine and ESHRE. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Update on Animal Models of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a complex disease affecting up to 15% of women of reproductive age. Women with PCOS suffer from reproductive dysfunctions with excessive androgen secretion and irregular ovulation, leading to reduced fertility and pregnancy complications. The syndrome is associated with a wide range of comorbidities including type 2 diabetes, obesity, and psychiatric disorders. Despite the high prevalence of PCOS, its etiology remains unclear. To understand the pathophysiology of PCOS, how it is inherited, and how to predict PCOS, and prevent and treat women with the syndrome, animal models provide an important approach to answering these fundamental questions. This minireview summarizes recent investigative efforts on PCOS-like rodent models aiming to define underlying mechanisms of the disease and provide guidance in model selection. The focus is on new genetic rodent models, on a naturally occurring rodent model, and provides an update on prenatal and peripubertal exposure models.

Pregnancy outcomes in patients with polycystic ovary syndrome who conceived after single thawed blastocyst transfer: a propensity score-matched study

Background

It remains unclear whether polycystic ovary syndrome (PCOS) is an independent risk factor for pregnancy complications in women undergoing assisted reproductive technology (ART) treatment. For the integrative treatment of PCOS patients, it is still important to investigate the pregnancy outcomes of PCOS patients after adjusting for potential biases, such as body mass index, embryo quality and endometrial preparation method.

Methods

This retrospective cohort study ultimately included a total of 336 PCOS patients who conceived after single thawed blastocyst transfer in the PCOS group and 2,325 patients in the control group from January 2018 to December 2020. A propensity score matching (PSM) model was used, and 336 PCOS patients were matched with 336 patients in the control group.

Results

Before PSM, no differences in the miscarriage rate, pregnancy complication rate, preterm birth rate, or live birth rate were found between the PCOS group and the control group. After PSM, the late miscarriage rate of the PCOS group was significantly higher than that of the control group (3.3% vs. 0.6%, P = 0.040), although the early miscarriage rates were similar (14.0% vs. 13.7%). The rates of pregnancy complications, preterm birth and live birth in the PCOS group were comparable to those in the matched control group (P = 0.080, P = 0.105, P = 0.109, respectively). The neonatal weights of male infants and female infants were similar between the two groups (P = 0.219, P = 0.169). Subgroup analysis showed that PCOS patients with homeostasis model assessment of insulin resistance (HOMA-IR) levels ≥ 2.49 had a significantly increased risk of preterm birth compared with those with HOMA-IR levels < 1.26 and 1.26 ≤ HOMA-IR levels < 2.49 (26.0% vs. 6.0% vs. 9.8%, P = 0.005). PCOS patients with total testosterone levels ≥ 0.7 ng/ml had a higher early miscarriage rate but a lower late miscarriage rate than those with total testosterone levels < 0.7 ng/ml (29.4% vs. 12.3%, 0% vs. 3.6%, respectively, P = 0.032).

Conclusions

PCOS is an independent risk factor for late miscarriage in patients conceived after a single thawed blastocyst transfer, even after adjusting for biases. Among PCOS patients, insulin resistance and hyperandrogenism are associated with a higher risk of preterm birth and early miscarriage, respectively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05011-4.

Effects of Exposure Duration and Exposure Levels of Ambient Air Pollutants on the Risk of Polycystic Ovarian Syndrome: A 2015-2019 Korean Population-Based Cohort Study

Exposure to ambient air pollution is associated with an increased risk of menstrual disorders and infertility. This study examined the relationships between the levels and duration of air pollution exposure and the risk of polycystic ovarian syndrome (PCOS) using Korean population-based cohort data (2015-2019). Real-time data on PM₁₀, PM_2.5, O₃, CO, SO₂, and NO₂ were provided by the Korean Ministry of Environment. The average monthly air pollutant concentration from 1 January 2014 to 31 December 2018 was analyzed. To assess individual-level exposure to air pollutants, a spatial prediction model and an area-averaging approach were used. In total, 237,582 PCOS cases were analyzed. The annual age-adjusted PCOS incidence was 6.70, 8.28, 9.73, 11.58, and 11.97% from 2015-2019, respectively. The PCOS risk increased 1.29-1.32, 1.43-1.52, and 1.32-fold following exposure to the 2-year and 3-year average levels of PM_2.5, O₃, and NO₂, respectively, compared to their 1-year average levels. The PCOS risk increased 1.75-fold (95% confidence interval: 1.66-1.85) in the fourth-quartile for the NO₂ level. Increased SO₂ and CO levels in the second- and third-quartiles were also associated with an increased PCOS risk. Exposure to air pollutants thus increased the risk for PCOS in the Korean population.

Effects of gestational diabetes mellitus and assisted reproductive technology treatment on the risk of preterm singleton birth

Background

Although assisted reproductive technology (ART) plays a critical role in reducing infertility, ART pregnant women are reported at higher risk of preterm birth (PTB). Besides, women undergoing ART encounter a higher risk of developing gestational diabetes mellitus (GDM). However, existing studies on the combined effect of ART treatment and GDM on PTB risk are sparse.

Methods

This population-based retrospective cohort study used nationwide birth certificate data from the US National Vital Statistics System 2015-2019. All mothers who had a singleton live birth without pre-pregnancy diabetes were included. Multivariable logistic regression models were used to estimate the odds ratio (OR) of PTB.

Results

We finally included 18,140,241 American mother-infant pairs. The overall rate of PTB was 7.92% (n = 1,436,328). The PTB rate for non-ART mothers without GDM, ART mothers without GDM, non-ART mothers with GDM, and ART mothers with GDM were 7.67, 10.90, 11.23, and 14.81%, respectively. The incidence of GDM in ART mothers (10.48%) was significantly higher than in non-ART mothers (6.26%). After adjusting for potential confounders, compared with non-ART mothers without GDM, the PTB risk was significantly increased for ART mothers without GDM (AOR: 1.47, 95% CI 1.44-1.50), non-ART mothers with GDM (AOR:1.35, 95% CI 1.34-1.36) and ART mothers with GDM (AOR: 1.82, 95% CI 1.74-1.90) respectively, showing an increasing tendency. This phenomenon was stable among mothers in all groups of mothers older than 25 years.

Conclusion

To prevent PTB, effective approaches for the prevention of GDM are crucial to mothers who conceived through ART.

Maternal polycystic ovarian syndrome and pubertal development in daughters and sons: a population-based cohort study

STUDY QUESTION

Does maternal polycystic ovarian syndrome (PCOS) affect the timing of pubertal development in daughters and sons?

SUMMARY ANSWER

Maternal PCOS was associated with earlier adrenarche in daughters.

WHAT IS KNOWN ALREADY

Female adolescents with PCOS often experience earlier adrenarche compared to adolescents without PCOS, due to hyperandrogenism. Likewise, they usually have hyperandrogenism during pregnancy, which might potentially affect the development of the foetus, including its future reproductive health.

STUDY DESIGN, SIZE, DURATION

In this population-based cohort study, we included 15 596 mothers-child pairs from the Danish National Birth Cohort (DNBC) Puberty Cohort, who were followed from foetal life until full sexual maturation or 18 years of age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Using register-based and self-reported information on maternal PCOS and menstrual irregularities, collected during pregnancy, we categorized the mothers as having PCOS (n = 251), oligomenorhoea (n = 134), 'other menstrual irregularities' (n = 2411) or no menstrual abnormalities (reference group, n = 12 800). The children provided self-reported information on pubertal development every 6 months from the age of 11 years. The main outcome measures were adjusted mean age differences (in months) at attaining several individual pubertal milestones using an interval-censored regression model, as well as the average difference in age at attaining all pubertal milestones combined into a single estimate using Huber-White robust variance estimation.

MAIN RESULTS AND THE ROLE OF CHANCE

We found that maternal PCOS was associated with an accelerated pubertal development in daughters with an overall average difference of -3.3 (95% CI: -6.3; -0.4) months based on all pubertal milestones compared to the reference group. When further looking into the average difference for adrenarche only (pubarche, axillary hair and acne), the average difference was -5.4 (95% CI: -8.7; -2.1) months compared to the reference group; whereas thelarche and menarche did not occur earlier in daughters of mothers with PCOS (average difference: -0.8 (95% CI: -3.9; 2.4) months). Oligomenorrhoea and 'other menstrual irregularities' were not associated with pubertal development in daughters. Neither PCOS, oligomenorrhoea nor 'other menstrual irregularities' were associated with pubertal development in sons.

LIMITATIONS, REASONS FOR CAUTION

We expect some degree of non-differential misclassification of maternal PCOS and menstrual irregularities as well as pubertal development in the children.

WIDER IMPLICATIONS OF THE FINDINGS

Maternal PCOS might accelerate adrenarche in daughters. Whether this is due to genetics, epigenetics or prenatal programming by hyperandrogenism in foetal life remains unsolved. The results from the present study can be generalized to Caucasian populations.

STUDY FUNDING/COMPETING INTEREST(S)

The study is funded by the Faculty of Health at Aarhus University. The authors have no financial relationships or competing interests to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) affects 5-18% of women, and is a reproductive, metabolic, and psychological condition with impacts across the lifespan. The cause is complex, and includes genetic and epigenetic susceptibility, hypothalamic and ovarian dysfunction, excess androgen exposure, insulin resistance, and adiposity-related mechanisms. Diagnosis is recommended based on the 2003 Rotterdam criteria and confirmed with two of three criteria: hyperandrogenism (clinical or biochemical), irregular cycles, and polycystic ovary morphology. In adolescents, both the criteria of hyperandrogenism and irregular cycles are needed, and ovarian morphology is not included due to poor specificity. The diagnostic criteria generates four phenotypes, and clinical features are heterogeneous, with manifestations typically arising in childhood and then evolving across adolescent and adult life. Treatment involves a combination of lifestyle alterations and medical management. Lifestyle optimisation includes a healthy balanced diet and regular exercise to prevent excess weight gain, limit PCOS complications and target weight reduction when needed. Medical management options include metformin to improve insulin resistance and metabolic features, combined oral contraceptive pill for menstrual cycle regulation and hyperandrogenism, and if needed, anti-androgens for refractory hyperandrogenism. In this Review, we provide an update on the pathophysiology, diagnosis, and clinical features of PCOS, and discuss the needs and priorities of those with PCOS, including lifestyle, and medical and infertility treatment. Further we discuss the status of international evidence-based guidelines (EBG) and translation, to support patient self management, healthcare provision, and to set research priorities.

Polycystic ovary syndrome and risk of adverse obstetric outcomes: a retrospective population-based matched cohort study in England

BACKGROUND

Polycystic ovary syndrome (PCOS) affects up to one in five women of childbearing age. Observational studies assessing the association between maternal PCOS and adverse obstetric outcomes have reported varying results, depending on patient population, diagnostic criteria for PCOS and covariates accounted for in their analyses. We aimed to assess the risk of obstetric outcomes among a population-based representative cohort of women with PCOS compared to an age-matched cohort of women without PCOS.

METHODS

A retrospective cohort study was conducted of pregnancies of women in England aged 15-49 years identified from the Clinical Practice Research Datalink (CPRD) GOLD pregnancy register and linked Hospital Episodes Statistic (HES) data between March 1997 and March 2020. Pregnancies from the register that had a linked HES delivery record were included. Linked CPRD primary care data was used to ascertain maternal PCOS exposure prior to pregnancy. To improve detection of PCOS, in addition to PCOS diagnostic codes, codes for (1) polycystic ovaries or (2) hyperandrogenism and anovulation together were also considered. Sensitivity analysis was limited to only pregnant women with a diagnostic code for PCOS. Primary outcomes ascertained from linked HES data were (1) preterm delivery (gestation < 37 weeks), (2) mode of delivery, (3) high (> 4000 g) or low birthweight (< 2500 g) and (4) stillbirth. Secondary outcomes were (1) very preterm delivery (< 32 weeks), (2) extremely preterm delivery (< 28 weeks), (3) small and (4) large for gestational age. Conditional logistic regression models were performed adjusting for age, ethnicity, deprivation, dysglycaemia, hypertension, thyroid disorders, number of babies born at index pregnancy, and pre-gravid BMI. Multiple imputation was performed for missing outcome data.

RESULTS

27,586 deliveries with maternal PCOS were matched for age (± 1 year) to 110,344 deliveries without PCOS. In the fully adjusted models, maternal PCOS was associated with an increased risk of (1) preterm birth [aOR: 1.11 (95% CI 1.06-1.17)], and (2) emergency caesarean, elective caesarean and instrumental vaginal compared to spontaneous delivery [aOR: 1.10 (1.05-1.15), 1.07 (1.03-1.12) and 1.04 (1.00-1.09), respectively]. There was absence of association with low birthweight, high birthweight and stillbirth. In the sensitivity analysis, the association with preterm birth [aOR: 1.31 (95% CI 1.13-1.52)], emergency caesarean [aOR: 1.15 (95% CI 1.02-1.30)], and elective caesarean [aOR: 1.03 (95% CI 1.02-1.03)] remained. While there was no significant association with any of the secondary outcomes in the primary analysis, in the sensitivity analysis maternal PCOS was associated with increased risk of extremely preterm delivery [aOR: 1.86 (95% CI 1.31-2.65)], and lower risk of small for gestational age babies [aOR: 0.74 (95% CI 0.59-0.94)].

CONCLUSIONS

Maternal PCOS was associated with increased risk of preterm and caesarean delivery. Association with low birthweight may be largely mediated by lower gestational age at birth.

Age-Adjusted Prevalence and Characteristics of Women with Polycystic Ovarian Syndrome in Korea: A Nationwide Population-Based Study (2010-2019)

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder in women of reproductive age and is associated with an increased risk of obesity, compensatory hyperinsulinemia, dyslipidemia, metabolic syndrome, and endometrial cancer. This study analyzed 544619 women using the Korean Informative Classification of Disease, version 10, codes E28.0-E28.9 in the population-based National Health Information Databases from 2010 to 2019. The age-adjusted incidence and prevalence rates of PCOS over 10 years among Korean women were 2.8% and 4.3%, respectively; and they increased in the late teens, peaked in the 20s, and began to decrease at the age of 30. We also found that the body mass index, levels of fasting blood glucose, and high-density lipoprotein values in the recent two years (2018-2019) were higher in women with PCOS compared to the general population. This is the first study to investigate the prevalence of PCOS in a nationwide population of reproductive-aged Korean women. Further research is needed to examine the short- and long-term health risks and psychological problems associated with PCOS.

Polycystic Ovary Syndrome: Insights from Preclinical Research

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, affecting approximately 10%. PCOS is diagnosed by the presence of at least two of these three criteria: hyperandrogenemia, oligo- or anovulation, and polycystic ovaries. The most common type (80%) of PCOS includes hyperandrogenemia. PCOS is also characterized by obesity or overweight (in 80% of US women with PCOS), insulin resistance with elevated plasma insulin but not necessarily hyperglycemia, dyslipidemia, proteinuria, and elevated BP. Although elevated compared with age-matched controls, BP may not reach levels considered treatable according to the current clinical hypertension guidelines. However, it is well known that elevated BP, even modestly so, increases the risk of cardiovascular disease. We have developed a model of hyperandrogenemia in rodents that mimics the characteristics of PCOS in women, with increases in body weight, insulin resistance, dyslipidemia, andproteinuria and elevated BP. This review discusses potential mechanisms responsible for the elevated BP in the adult and aging PCOS rat model that may be extrapolated to women with PCOS.

The incidence of gestational diabetes mellitus among women with polycystic ovary syndrome: a meta-analysis of longitudinal studies

BACKGROUND

Previous studies have shown that polycystic ovary syndrome is a predictor of gestational diabetes mellitus, but we do not know exactly how many polycystic ovary syndrome patients may develop gestational diabetes mellitus. Currently, the incidence of gestational diabetes mellitus among women with polycystic ovary syndrome varies greatly across studies, ranged from 4.12% to 59.50%. Besides, many factors have been found to be related to the incidence of gestational diabetes mellitus among women with polycystic ovary syndrome, but the results among different studies are not consistent. The possible causes of inconsistencies between the current estimates were unclear. This review aimed at exploring the pooled incidence of gestational diabetes mellitus among women with polycystic ovary syndrome, summarizing possible causes of the inconsistencies in the current estimates, try to provide a reference for prevention of gestational diabetes mellitus and polycystic ovary syndrome in the future.

METHODS

Systematic searches of different databases (including EMBASE, Web of Science, MEDLINE, The Cochrane Library, CNKI and PubMed) were conducted for studies published until 31 May 2021. Statistical analyses were performed using R software, the pooled incidence of gestational diabetes mellitus among polycystic ovary syndrome patients was combined using random effects model. Cochrane's "Tool to Assess Risk of Bias in Cohort Studies" was used for quality assessment.

RESULTS

Twenty-two longitudinal studies were included. A total of 24,574 women with polycystic ovary syndrome were identified in the 22 articles, of which 4478 were reported with gestational diabetes mellitus. The pooled incidence of gestational diabetes mellitus among women with polycystic ovary syndrome was 20.64%, with a 95% CI of 14.64% to 28.30%. In the meta-regression model, several variables including age, area, quality score and sample size were suggested as significant sources of heterogeneity, accounted for 77.57% of the heterogeneity across studies.

CONCLUSIONS

Evidence in this review suggests that gestational diabetes mellitus were common among women with polycystic ovary syndrome. More research is needed to found effective interventions for preventing gestational diabetes mellitus among women with polycystic ovary syndrome.

Development and evaluation of an online questionnaire to identify women at high and low risk of developing gestational diabetes mellitus

BACKGROUND

Established risk factors for Gestational Diabetes Mellitus (GDM) include age, ethnicity, family history of diabetes and previous GDM. Additional significant influences have recently been demonstrated in the literature. The oral glucose tolerance test (OGTT) used for GDM diagnosis has sub-optimal sensitivity and specificity, thus often results in GDM misdiagnoses. Comprehensive screening of risk factors may allow more targeted monitoring and more accurate diagnoses, preventing the devastating consequences of untreated or misdiagnosed GDM. We aimed to develop a comprehensive online questionnaire of GDM risk factors and triangulate it with the OGTT and continuous glucose monitoring (CGM) parameters to better evaluate GDM risk and diagnosis.

METHODS

Pregnant women participating in two studies on the use of CGM for GDM were invited to complete the online questionnaire. A risk score, based on published literature, was calculated for each participant response and compared with the OGTT result. A total risk score (TRS) was then calculated as a normalised sum of all risk factors. Triangulation of OGTT, TRS and CGM score of variability (CGMSV) was analysed to expand evaluation of OGTT results.

RESULTS

Fifty one women completed the questionnaire; 29 were identified as 'high-risk' for GDM. High-risk ethnic background (p < 0.01), advanced age, a family diabetic history (p < 0.05) were associated with a positive OGTT result. The triangulation analysis (n = 45) revealed six (13%) probable misdiagnoses (both TRS and CGMSV discordant with OGTT), consisting of one probable false positive and five probable false negative by OGTT results.

CONCLUSIONS

This study identified pregnant women at high risk of developing GDM based on an extended evaluation of risk factors. Triangulation of TRS, OGTT and CGMSV suggested potential misdiagnoses of the OGTT. Future studies to explore the correlation between TRS, CGMSV and pregnancy outcomes as well as additional GDM pregnancy biomarkers and outcomes to efficiently evaluate OGTT results are needed.

Association between polycystic ovarian syndrome and risk of gestational diabetes mellitus: A meta-analysis

OBJECTIVES

The results of studies regarding the association between polycystic ovary syndrome (PCOS) and gestational diabetes mellitus (GDM) are controversial.

DESIGN

This meta-analysis was conducted to evaluate the relationship between PCOS and GDM.

METHODS

English language articles published before July 2021 were included by searching in databases: PubMed, EMBASE, Web of Science, Medline and Google Scholar. All these results were computed using STATA 12.0 software. The random-effects models were used to calculate summary odds ratio (OR) or relative risk (RR) and 95% confidence interval (CI) when the heterogeneity was high; Inversely, the fixed-effects models were used to calculate summary OR/RR and 95% CI when the heterogeneity was low.

RESULTS

The present study showed that PCOS was significantly associated with an increased risk of GDM with a random effects model (OR/RR = 2.02, 95% CI 1.74 to 2.34, I2 = 79.5%, p < 0.0001). Subgroup analysis indicated an elevated risk of GDM in PCOS patients in both retrospective and prospective studies (retrospective studies: OR = 1.89, 95% CI 1.62 to 2.20; prospective studies: RR = 2.85, 95% CI 1.77 to 4.60). In addition, subgroup analysis indicated an elevated risk of GDM in PCOS patients in both Caucasian and Asian populations (Caucasian populations: OR/RR = 2.47, 95% CI 1.99 to 3.07; prospective studies: OR/RR = 1.58, 95% CI 1.23 to 2.02).

CONCLUSION

Overall, findings of the meta-analysis showed that women with PCOS have an elevated risk of GDM compared to women without PCOS.

LIMITATIONS

First, on account of sources of information, the role of several variables including BMI, the severity of GDM and serum lipid level in the association between PCOS and GDM can not be evaluated. Second, only studies published in English and Chinese were included, and the publish bias is impossible to avoid.

Gestational Diabetes Mellitus and Preeclampsia: Correlation and Influencing Factors

Gestational diabetes mellitus (GDM) and preeclampsia (PE) are common pregnancy complications with similar risk factors and pathophysiological changes. Evidence from previous studies suggests that the incidence of PE is significantly increased in women with GDM, but whether GDM is independently related to the occurrence of PE has remained controversial. GDM complicated by PE further increases perinatal adverse events with greater impact on the future maternal and offspring health. Identify factors associated with PE in women with GDM women, specifically those that are controllable, is important for improving pregnancy outcomes. This paper provides the findings of a review on the correlation between GDM and PE, factors associated with PE in women with GDM, possible mechanisms, and predictive markers. Most studies concluded that GDM is independently associated with PE in singleton pregnancy, and optimizing the treatment and management of GDM can reduce the incidence of PE, which is very helpful to improve pregnancy outcomes.

OUP accepted manuscript

STUDY QUESTION

Is the presence of polycystic ovary syndrome (PCOS) associated with more adverse infant outcomes in mothers with different types of diabetes?

SUMMARY ANSWER

The presence of PCOS implies higher risks of total (medically indicated and spontaneously combined) and spontaneous preterm birth in mothers with non-insulin-treated type 2 diabetes and gestational diabetes mellitus (GDM), and lower risk of offspring being large for gestational age (LGA) in mothers with insulin-treated diabetes.

WHAT IS KNOWN ALREADY

PCOS is suggested to be an independent risk factor for adverse infant outcomes, and it is highly prevalent in mothers with diabetes. However, the impact of PCOS on the associations of different types of maternal diabetes with preterm birth and offspring birth sizes has not been reported.

STUDY DESIGN, SIZE, DURATION

This is a population-based cohort study including all live births between 1996 and 2014 in Finland. Children with concurrent maternal diagnoses that could cause signs and symptoms similar to PCOS were excluded. A total of 1 097 753 children were included.

PARTICIPANTS/MATERIALS, SETTING, METHODS

National registries were linked to identify births with maternal PCOS (n = 24 682), stratified by diabetes types. Logistic regression was used to examine the association of maternal PCOS and comorbid insulin-treated diabetes, non-insulin-treated type 2 diabetes or GDM with offspring LGA and small for gestational age (SGA). Generalized estimating equation was used to assess the risk of preterm birth in relation to maternal PCOS and diabetes. Potential interaction between PCOS and diabetes was evaluated on both additive and multiplicative scales.

MAIN RESULTS AND THE ROLE OF CHANCE

Using mothers with no PCOS and no diabetes as the reference and adjusting for maternal and birth factors, there were higher risks of total (odds ratio (OR) 2.84, 95% CI 2.21 − 3.66 vs. OR 1.91, 95% CI 1.77 − 2.07, P = 0.01) and spontaneous (OR 4.02, 95% CI 2.94 − 5.50 vs. OR 2.35, 95% CI 2.13 − 2.59, P = 0.001) preterm birth for those with PCOS in mothers with non-insulin-treated type 2 diabetes and higher risks of total (OR 1.42, 95% CI 1.27–1.58 vs. OR 0.89, 95% CI 0.86–0.91, P = 0.0001) and spontaneous (OR 1.80, 95% CI 1.59–2.05 vs. OR 1.01, 95% CI 0.98–1.05, P = 0.0001) preterm birth for those with PCOS in mothers with GDM. Among mothers with type 2 diabetes, further adjusting for maternal BMI eliminated the difference in preterm birth risks between those with and those without PCOS, and adjustment for infertility treatment and pre-eclampsia also reduced the preterm risks associated with PCOS significantly. For mothers with GDM, however, the risks of total and spontaneous preterm birth remained higher for those with PCOS following these aforementioned adjustments or stratified analysis. The risk of offspring being LGA was lower for those with PCOS than those without PCOS among mothers with insulin-treated diabetes (OR 18.90, 95% CI 14.21–25.14 vs. OR 32.04, 95% CI 29.79–34.46, P = 0.0001), showing departure from additivity (relative excess risk due to interaction −11.74, 95% CI −16.17 to −7.31, P < 0.001) and multiplicativity (P < 0.001). PCOS did not alter the risk estimate of preterm birth in mothers with insulin-treated diabetes or offspring LGA and SGA in mothers with type 2 diabetes or GDM.

LIMITATIONS, REASONS FOR CAUTION

The register-based diagnoses used in this study captured only women with PCOS seeking medical care and having live births. Including female infertility associated with anovulation as PCOS exposure was a risk for misclassification. Sample sizes for pregestational diabetes were small. Insulin purchase during pregnancy in those without a diabetes diagnosis was not accounted for in the analysis. For patients treated with insulin or other medications, we were unable to assess how they complied with such prescriptions. Also, maternal BMI was recorded only once in early pregnancy, thus the potential influence of gestational weight gain on birth outcomes could not be examined. Data on the causes for preterm birth were not available from the registers.

WIDER IMPLICATIONS OF THE FINDINGS

The presence of PCOS implied higher risks of total and spontaneous preterm birth in mothers with type 2 diabetes or GDM, and lower risk of offspring being LGA in mothers with insulin-treated diabetes. The higher risks of preterm birth added by PCOS could be explained by prepregnancy BMI or in part by infertility treatment and pre-eclampsia in maternal non-insulin-treated type 2 diabetes, but not in maternal GDM. The differential effects of PCOS on the associations of different types of maternal diabetes with infant outcomes have implications for preventative strategies and clinical counseling for affected pregnancies.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by Shandong Provincial Natural Science Foundation, China (ZR2020MH064 to X.C.), Shandong Province Medical and Health Technology Development Plan (2018WS338 to X.C.), the joint research funding of Shandong University and Karolinska Institute (SDU-KI-2019-08 to X.C. and C.L.), the Finnish National Institute for Health and Welfare: Drug and pregnancy project (M.G.), the Swedish Research Council (2014-10171 to C.L.), the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institute Stockholm County Council (SLL20170292 and SLL20190589 to C.L.), the Swedish Brain Foundation (FO2019-0201 and FO2020-0305 to C.L.). X.C. received grants from the China Scholarship Council at the beginning of the study. The authors have no competing interests to disclose.

TRIAL REGISTRATION NUMBER

N/A.

An early model to predict the risk of gestational diabetes mellitus in the absence of blood examination indexes: application in primary health care centres

Background

Gestational diabetes mellitus (GDM) is one of the critical causes of adverse perinatal outcomes. A reliable estimate of GDM in early pregnancy would facilitate intervention plans for maternal and infant health care to prevent the risk of adverse perinatal outcomes. This study aims to build an early model to predict GDM in the first trimester for the primary health care centre.

Methods

Characteristics of pregnant women in the first trimester were collected from eastern China from 2017 to 2019. The univariate analysis was performed using SPSS 23.0 statistical software. Characteristics comparison was applied with Mann-Whitney U test for continuous variables and chi-square test for categorical variables. All analyses were two-sided with p < 0.05 indicating statistical significance. The train_test_split function in Python was used to split the data set into 70% for training and 30% for test. The Random Forest model and Logistic Regression model in Python were applied to model the training data set. The 10-fold cross-validation was used to assess the model’s performance by the areas under the ROC Curve, diagnostic accuracy, sensitivity, and specificity.

Results

A total of 1,139 pregnant women (186 with GDM) were included in the final data analysis. Significant differences were observed in age (Z=−2.693, p=0.007), pre-pregnancy BMI (Z=−5.502, p<0.001), abdomen circumference in the first trimester (Z=−6.069, p<0.001), gravidity (Z=−3.210, p=0.001), PCOS (χ²=101.024, p<0.001), irregular menstruation (χ²=6.578, p=0.010), and family history of diabetes (χ²=15.266, p<0.001) between participants with GDM or without GDM. The Random Forest model achieved a higher AUC than the Logistic Regression model (0.777±0.034 vs 0.755±0.032), and had a better discrimination ability of GDM from Non-GDMs (Sensitivity: 0.651±0.087 vs 0.683±0.084, Specificity: 0.813±0.075 vs 0.736±0.087).

Conclusions

This research developed a simple model to predict the risk of GDM using machine learning algorithm based on pre-pregnancy BMI, abdomen circumference in the first trimester, age, PCOS, gravidity, irregular menstruation, and family history of diabetes. The model was easy in operation, and all predictors were easily obtained in the first trimester in primary health care centres.